Provider Demographics
NPI:1710387766
Name:VERGARA, PETRA (MSW)
Entity Type:Individual
Prefix:MS
First Name:PETRA
Middle Name:
Last Name:VERGARA
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 ARLINGTON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90018-1353
Mailing Address - Country:US
Mailing Address - Phone:323-737-3900
Mailing Address - Fax:323-737-3993
Practice Address - Street 1:2116 ARLINGTON AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1353
Practice Address - Country:US
Practice Address - Phone:323-737-3900
Practice Address - Fax:323-737-3993
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW72404101YM0800X
CA1072911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health